|Year : 2016 | Volume
| Issue : 3 | Page : 195-202
Comparison of satisfaction with maternal health-care services using different health insurance schemes in aceh province, Indonesia
Zurnila Marli Kesuma1, Virasakdi Chongsuvivatwong2
1 Senior Lecturer, Department of Mathematics, Faculty of Mathematics and Natural Sciences, Syiah Kuala University, Banda Aceh, Indonesia
2 Professor, Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
|Date of Web Publication||24-Aug-2016|
Dr. Zurnila Marli Kesuma
Department of Mathematics, Faculty of Mathematics and Natural Sciences, Syiah Kuala University, Banda Aceh 23111
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: An insurance scheme called Jaminan Kesehatan Aceh (JKA) was established by the local government to achieve universal coverage for Aceh's population who were not registered under the national insurance scheme for the poor (Jamkesmas). Objective: This study was conducted to compare women's satisfaction before and after the implementation of JKA and across different insurance schemes. Methods: The study was conducted from July 2011 to July 2012 on satisfaction of maternal health services among 1197, 15-49 years aged old women living in eight districts of Aceh Province, Indonesia, and a cluster sampling technique was applied. Analysis of variance was used to assess the effects of different insurance schemes, period, and type of services on satisfaction with maternal health services. Results: Women were mostly satisfied with birth delivery services (mean score: 2.69) followed by postnatal care (mean score: 2.62) and antenatal care services (mean score: 2.37). Conclusion: Over the changing period, the average level of satisfaction in the JKA group increased significantly.
Keywords: Aceh Province, insurance scheme, maternal health-care services, satisfaction
|How to cite this article:|
Kesuma ZM, Chongsuvivatwong V. Comparison of satisfaction with maternal health-care services using different health insurance schemes in aceh province, Indonesia. Indian J Public Health 2016;60:195-202
|How to cite this URL:|
Kesuma ZM, Chongsuvivatwong V. Comparison of satisfaction with maternal health-care services using different health insurance schemes in aceh province, Indonesia. Indian J Public Health [serial online] 2016 [cited 2019 Nov 19];60:195-202. Available from: http://www.ijph.in/text.asp?2016/60/3/195/189013
| Introduction|| |
Utilization of maternal health-care services and satisfaction has a positive relationship, and this helps to reduce maternal mortality and morbidity.  When women utilize these services and feel satisfied, it may lead them to use these services regularly and adhere to professional recommendations thus reducing their risk for developing serious problems. 
The WHO promotes skilled birth attendance during delivery to reduce maternal mortality and recommends that women's satisfaction be assessed to improve the quality and effectiveness of health care.  Satisfaction of patients' has been increasingly recognized as an important outcome for health-care delivery systems  and is increasingly studied in developing countries. ,
Indonesia has a relatively high maternal mortality ratio compared to other Southeast Asian countries. The rate in 2010 was 220 per 100,000 live births.  The lifetime risk of a mother dying related to childbirth in Indonesia is estimated to be 1 in 210, compared to Thailand where it is only 1 in 1400. , Late arrival to health facilities during emergencies and delays in obtaining adequate services by health workers are the main contributors. ,
Aceh is the Northwesternmost province of Indonesia. The area has been affected by violence from human conflict and natural disasters, notably the 2004 tsunami, over the past decade. Twenty percent of the households lived in poverty in 2009, which is an important barrier to necessary health care.
The first national attempt at universal health-care coverage came in 1968 when an insurance scheme known as Askes was established for active and pensioned civil servants and their direct family members. Since the early 2000s, the country has been heading toward universal health coverage via Jaminan Kesehatan Masyarakat (Jamkesmas), which was formerly called the Askeskin scheme.  In 2008, Jamkesmas could cover only 71% of Aceh's population due to financial limitations of the government. In 2010, therefore, the Aceh government established its own universal coverage scheme called Jaminan Kesehatan Aceh (JKA). Aceh was the first province in Indonesia where people could attain universal health coverage. JKA fully covers all maternal health care run by government health facilities. ,
While universal coverage has become a global trend, low levels of satisfaction have been reported from people in several countries. In India, the percentage of postnatal mothers who were fully, moderately, and minimally satisfied with nursing personnel care was 1%, 39%, and 60%, respectively.  In Bangladesh, service orientation of doctors and nurses were found to be strong factors influencing patient satisfaction.  In Ghana, maternal satisfaction during delivery is determined mostly by the attitude of caregivers.  When universal coverage has turned into action, comparing the effectiveness of health insurance for the improvement of maternal health services in underdeveloped area is very beneficial.
Two years after JKA was established, we evaluated the program to see the effects of universal coverage on satisfaction of women toward maternal health-care services. The objective of this communication is to compare the level of women satisfied with maternal health-care services among those using different health insurance schemes before and after JKA was implemented.
| Materials and Methods|| |
The research proposal was approved by the Ethics Committee of the Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand, before the study was conducted.
This study was carried out in eight districts included Singkil, Aceh Barat, Aceh Barat Daya, Aceh Selatan, Pidie, Nagan Raya, Aceh Jaya, and Aceh Timur. Simeulue, Gayo Lues, and Bener Meriah districts were not included due to the ongoing political turmoil during the period of data collection. The survey was conducted in Aceh Province Indonesia from July 2011 to July 2012. Study participants were women who were covered by different health insurance schemes and experienced different time periods of maternal health services.
Study setting and study population
Every woman in the study area is covered by an insurance scheme which is classified by the government standard. The government officers and their families were covered by the Askes scheme. Those not covered by Askes would be covered by the Jamkesmas or JKA schemes. The registration of Jamkesmas scheme for the poor was done by the central government with specific criteria. The poor, who were not covered by Jamkesmas, would be covered by the Aceh government through the JKA scheme.
Eligibility criteria included currently married women, aged between 15 and 49 years, and living in the study area for at least 6 months before being interviewed. Only married women were included because Islamic law forbids two people to live together if they are not married.
For the assessment of maternal health-care services, the women must had experienced pregnancy and be eligible to receive antenatal care (ANC), delivery, and postnatal care (PNC) services in one period of the 24-month study periods (April 1, 2009-May 31, 2011). For period "before," women must have a child born between January 1, 2009, and November 30, 2009. For period "during," women must have a child born between December 1, 2009, and June 30, 2010. For period "after," women must have a child born between July 1, 2010, and May 31, 2011.
It is expected that before, during, and after the establishment of JKA, a woman can be eligible for relevant maternal health services across these three periods. Every woman must have experienced within all three services to be eligible for this study. Detailed numbers of women were presented in [Figure 1]. Women with serious mental problems were excluded from the study.
|Figure 1: Number of women in the study period of maternal health services|
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Three different periods of JKA were as follows: Before JKA (within 9 months before JKA started), during the JKA transition (from starting day to the end of the first 6 months), and after JKA had been established (from 7 to 15 months post-JKA). In this study, during JKA transition period were excluded from the study.
The prevalence of women satisfied with maternal health services was assumed to lie between 20% and 70% before the implementation of JKA. A sample size of 1125 (375 women in each scheme) would have 80% power to detect an odds ratio of at least 2.0 between different health insurance schemes with a significance level of 0.05 and a design effect of 1.5. The current sample size of this study (1197) was sufficient to compare the proportion of women satisfied using different health insurance schemes.
A cluster sampling technique was conducted. First, the list of all villages from eight selected districts and their total population of women aged 15-49 years were obtained from the Central Bureau of Statistics (BPS). Based on the Millennium Development Goals (MDGs) survey guideline from BPS, twenty villages were chosen using probability proportional to size.  Each selected village was visited and divided into three approximately equal regions. For each region, a research assistant went into the center of the region, randomly chose a direction to move, and consecutively visited all houses in that direction until around sixty consent subject were achieved, and the required sample size was met. At each study village, a random starting household was selected, then any subsequent nearest house was visited to identify eligible women until around 68 consent subject were achieved.
The study variables included demographic and reproductive characteristics of the women and satisfaction of maternal health services for ANC, delivery care, and PNC. According to the WHO, for ANC, there were two assessments, i.e., ANC 1 (at least one visit in the first trimester) and ANC 4 (ANC1 + at least one visit in the second trimester and at least two in the third). For delivery and PNC, a woman should receive the services by skilled health personnel.
Satisfaction of each service was assessed using a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. The satisfaction scores were assessed separately for ANC, delivery care, and PNC. We took each subscale as a separate outcome variable. For each service, items were adopted from previous questionnaires. 
Pilot study process
To strengthen the internal validity of the results, a pilot study was conducted to evaluate the precision and accuracy of the instruments involving ninety participants. After the pilot study, the items were assessed for reliability using Cronbach's alpha coefficient. Any item which was poorly correlated with the others was removed from the analysis.
Six research assistants were trained for interviewing technique, data coding, and checking the completeness of the questionnaires. Before the interviews, every woman was informed about the objectives of the study and assured for confidentiality. If there were more than one eligible woman in a selected household, all were interviewed.
Data were computerized using EpiData (The Epi-Data Association, Odense Denmark, version 3.1 for windows) and analyzed with R software (R Foundation for Statistical Computing, Vienna, Austria version 2.14.2). The satisfaction score of the women was presented as means. After checking of the normality distribution of the scores, comparison of satisfaction scores was assessed by Student's t-test.
Analysis of variance (ANOVA) was used to test difference in satisfaction with maternal health services stratified by various factors. The effects of different insurance schemes, period, and type of services were simultaneously evaluated using multiple linear regression. After adjusting for socioeconomic and reproductive characteristics, the final model was chosen based on keeping only variables, the model with or without which would not be significantly different by multivariable ANOVA test.
| Results|| |
Of the 1360 women approached, 1197 (88%) consented to participate and completed the interview. Most women were aged between 30 and 39 years. Women in the Askes insurance scheme had a higher education than women in other schemes, were less engaged in housework, and had husbands who were more likely to work as government officer. In summary, women in the Askes insurance scheme were different to women using the JKA and Jamkesmas schemes. For reproductive characteristics, women in the three insurance schemes had different distributions of age at first delivery, gravidity, parity, number of living children, while the history of abortions and preterm births were similar.
[Table 1] presents the reliability analysis and item correlation for each maternal health service. If any item of delivery or PNC is removed, the reliability coefficient would be reduced. Therefore, none were removed. In ANC, four items were removed, since this led to an improvement in item the reliability. The final Cronbach's alpha coefficient for items in the ANC, delivery, and PNC sections of the questionnaire were 0.75, 0.88, and 0.91, respectively.
|Table 1: Cronbach's alpha for antenatal care, delivery, and postnatal care satisfaction items |
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[Table 2] compares the mean satisfaction scores of women toward maternal health services among the three different insurance schemes. In general, women in all schemes were equally satisfied with maternal health services. Out of 12 items, only one was significantly different among any of the three schemes. Among them, the JKA group had the highest or second highest mean satisfaction score for all items except for emergency health care during ANC. Women covered by JKA were more satisfied with the ease of medical specialists, compared to those who were covered by Askes and Jamkesmas. For information about preparation for admission in the birth center and what to expect on arrival, women in JKA and Askes schemes were more satisfied with this aspect of the service while women in Jamkesmas were least satisfied. Overall, women utilizing delivery care services had the highest mean satisfaction score, followed by PNC, and ANC services.
|Table 2: Comparison of women's satisfaction with maternal health services by user of different insurance scheme |
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[Table 3] shows a comparison of women's satisfaction with maternal health services before and after JKA was established. Overall, before implementation, the mean satisfaction score for ANC services was the lowest (2.4) followed by PNC (2.6) while delivery care had the highest (2.7). The mean satisfaction score for ANC and delivery care services was significantly increased after the implementation of JKA. For ANC, three out of four items were significantly increased after the implementation of JKA. For delivery care, two items were significantly increased but no significant change in PNC items was observed.
|Table 3: Comparison of women's satisfaction with maternal health services before and after Jaminan Kesehatan Aceh was established |
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[Table 4] shows the final predictors of women's satisfaction with maternal health-care services from the multiple linear regression. There was a significant interaction between type of insurance scheme and period of JKA (P = 0.011). Over the changing period, the average level of satisfaction among the JKA group significantly increased while for Askes and Jamkesmas groups, satisfaction levels were unchanged.
|Table 4: Predictors of women's satisfaction with maternal health services from multiple linear regression |
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There was a significant effect of different types of services. Women using PNC services had significantly higher satisfaction scores than women using ANC services after adjustment for type of insurance and period of study.
| Discussion|| |
In this study, women in the JKA scheme were similar to those in Jamkesmas but were younger less educated and had more children than women in Askes. Both JKA and Jamkesmas insurance schemes target the poor while the Askes scheme is restricted to government employees and their families. The JKA group had a higher mean satisfaction score with maternal health services than the other insurance groups in the initial analysis. After the establishment of JKA, JKA group mean score increased and significantly more so than women in the other two insurance groups, except the mean satisfaction score to get health care in an emergency was lower after implementation of JKA. This problem may occur due to the number of women who needed the emergency service were increased. In conclusion, ANC services require more attention to facilitate achievement of MDG 5. Improving the perceived quality of care in the ANC included engendering more user-friendly attitudes in the health personnel. 
Women's satisfaction of PNC services may also be influenced by psychological factors, such as happiness to have a new baby, regardless of the level of service provided by midwives and nurses, considering most of the women in our study only had two children. This is not surprising. Conversely, a previous study from Nairobi also identified that unwanted pregnancy was associated with lower satisfaction if women were unhappy about giving birth, a fact that can affect their view of delivery experience, and satisfaction. 
In Aceh Province, large-sized families dominate and the culture prevailing in this society before and after giving birth may have resulted in the lower satisfaction toward ANC services. On the other hand, lower satisfaction on ANC probably due to pregnant women's reliance on other people (extended family, neighbors) to facilitate their access to care. Another study in Kalimantan Indonesia noted that factors contributing maternal deaths were including delay in reaching health provider or facility and poor quality of care by health provider and/or at health facility. Transportation and unclear mechanism were identified as main barriers for ANC and delivery. 
A study in India noted that the factors that provided higher satisfaction on PNC services were the baby's health condition, care received during the postnatal period, and health advice given by the provider.  A study in Australia showed that women's management of postnatal depression, such as feeling depressed, or lack of personal voice could also impact on their satisfaction level. 
| Conclusion|| |
Implementation of JKA increased the satisfaction of maternal health-care services among women of JKA schemes, perhaps through the fact that receiving the new health insurance from the government makes the poor more satisfied with and grateful for the new service. For women who were covered by Askes and Jamkesmas, they may not have felt so impressed anymore because they had been covered by their insurance schemes for a long time.
The first limitation of this study is that the main outcomes were obtained from the women's perceptions and response and not objectively measured or confirmed by medical reports. Second, due to the cross-sectional study design, we cannot know whether changes in satisfaction over time (from before to after implementation of JKA) among women under different insurance schemes can be causally attributed to the implementation of this new insurance scheme or due to natural changes over time. Third, our results can only be generalizable to married women. Finally, the data were based on recall, which might be biased.
Despite the aforementioned limitations, our findings suggest that satisfaction of maternal health services has improved after the introduction of JKA in Aceh Province. This trend toward more equitable and quality health services should be further enhanced.
The authors would like to thank the officers of the surveyed counties for their support and coordination, the interviewers for their excellent fieldwork, and all participants of the villages and households for their cooperation in the study. Special thanks to Mr. Edward McNeil, the Epidemiology Unit, Faculty of Medicine, PSU, for providing assistance in data analysis and manuscript editing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]